Inpatient or outpatient - What’s the difference?

When looking for a new international health insurance plan in China, one of the first questions brokers and providers will ask is whether you want an inpatient only plan or a plan with inpatient and outpatient cover. Similarly, when you visit the hospital you may hear the doctors discussing whether your treatment will be inpatient or outpatient. Because this term is used by both doctors and insurers, there can be some confusion about the difference between these two terms. To help clear this up, let’s take a look at these terms.

Inpatient and outpatient in the hospital setting

In a medical facility, these terms are almost always used to differentiate between the type of medical care you will be receiving and are often defined as:

Inpatient care: Procedures that require the patient to be admitted to hospital by a doctor. Generally speaking, when you are ‘admitted’ you will be under observation and care from nurses and doctors, but it doesn’t have to always be overnight. Because inpatient procedures revolve around admission, you will rarely see clinics or office style medical facilities that offer inpatient care.

Outpatient care: Also referred to as ambulatory care, is medical care where you are not required to stay under the care of doctors for more than 24 hours. The vast majority of these cases are usually things like day surgeries, also known as daycare treatment, where you go in the morning and return home in the afternoon to recover, or clinic visits where you see a doctor for diagnosis and treatment and then go home. As a general rule of thumb, almost all clinics that are not in hospitals (e.g. in an office tower) will be outpatient.

An example of this in practice in China is if you go to the hospital because you are feeling unwell and see a doctor. When you first arrive you will be considered an outpatient - because you have not been referred by another doctor or admitted. Only when the doctor or hospital chooses to admit you will you become an inpatient.

Inpatient and outpatient in insurance terms

In the insurance industry, these two terms are used by health insurers usually to refer to benefits included in the plans they are selling, and are defined as follows:

Inpatient benefits: These are the most basic level of plans sold by insurers in China and are often sold as “inpatient only” plans. This means they will only cover costs if you are admitted to hospital for a minimum amount of time - usually 24 hours, or for major medical surgeries and catastrophic accidents. Beyond that, some insurers with inpatient only plans will or will not cover pre/post-surgery outpatient follow-up. In other words, only the costs directly related to the actual surgery will be considered.

Outpatient benefits: Plans with outpatient benefits will usually cover medical care where you are either not admitted to the hospital (ambulatory care) or are in the hospital for less than a set period (usually less than 24 hours). Because of the way many health insurance plans in China are set up, outpatient plans will also include inpatient coverage.

For many insurers, the key difference is based on the time spent in the hospital or clinic more than actually being admitted. This is why if you say break your arm and need to go to the emergency room, but are not admitted for more than 24 hours, your insurer may deem this as outpatient care; thus only providing coverage if you have outpatient insurance. However, the hospital would label this as an inpatient procedure (because you have been admitted for care, including x-rays, etc). In this case, to know whether you will be covered for care or not, it’s important to look at the advanced imagery and X-ray benefits of your plan - which can usually be found in the documentation provided when you signed up for your health insurance plan.

Of course, insurers will often define these benefits differently. For example, a local health insurance plan will usually be quite tight on their definition of the two, which means it may be harder to submit a successful claim with this type of insurance. International insurance providers, however, are often more lenient with their coverage, meaning you stand a better chance of a successful claim.